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"In Network": a quick 411

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

 

July 24, 2024


"In Network" can be a requirement, incentive, choice, financial benefit and more.

Let's go over the basics, and see how best to use this option.


A. What is this "Network"?


  • It is the list compiled and maintained by your insurance plan, which includes all the providers that have agreed to a special financial agreement

  • "in network" = "contracted"

  • Both medical providers, insurance companies and you receive incentives every time you use a Network provider


B. What is a "provider"?


It can be:

  • a professional individual working in their own office or within a medical group: Primary Care Physicians, Specialists MDs, Mental Health Therapists, occupational, physical, speech Therapists, Home health agencies,

    Nurse Practitioners and Physician Assistants

  • a professional individual working in a hospital or facility:

    ER Drs,

    Radiologist, Anesthesiologists,

    Pathologists, Hospitalists, Medical Directors

  • It can also be a building, place, location,“facility” 

    where services are rendered and whose equipment, staff, beds, supplies, drugs, machines are being used by patients for a period of time that can range from an hour (or less) to more than a day, or longer: ER, hospitals, surgicenters,

    Residential facilities, Labs, Pharmacies , Urgent care centers, Imaging centers,

    Infusions centers, Ambulance, Skilled Nursing Facilities.


C. How does it work?


  1. A Provider signs a contract 

    or special agreement with 

    your insurance/plan. 

    They are now “in network”

  2. The provider accepts

     a reduced set fee for each service/item/supply/procedure/Rx they provide to members of that insurance plan, in 

    return for certain benefits: faster payment, direct payment, less administrative hassles, no need for authorization or easier to obtain, preferred funneling of new patients, financial security, and more.

  3. The provide sends a claim form to your plan after each service, which contains coded data detailing what was performed and/or provided.

  4. The insurance system uses the codes to calculate an "allowance" for each service, based on the terms of the contract.

  5. Payment is issued to the provider, except for any portion of the allowance that is applied toward the member's share of cost (deductible, copay, co-insurance)

  6. The difference between the amount billed by the provider and the "allowance' (or set contracted rate) is a write off (called "adjustment") for the provider, and a discount to you (and your insurance)


D. Advantages for patients


  1. Administratively:


  • easier, faster access to care

  • privileged treatment

  • no-involvement claim submission, processing and appeal

  • preferential payment terms for any liability

  • easier authorization process

2. Clinically:

  • vetted providers

  • free preventive services for all members of the family

  • +/- extensive list of providers locally, within State, and around whole country


3. Financially:

  • Discount on all services, procedures, supplies etc

  • Lowest overall share of cost and liability

  • Highest payment by insurance


4. Overall:

  • Best use of your policy

  • Most advantageous benefits

  • Best way to save $


E. Some Tips


  1. Some out of network providers might be considered “In network” and paid more by your insurance in some circumstances:

  • emergency services

  • services rendered at an In Network facility when you had no choice of an in network provider (or of hiring one)

  • if the Law (state of federal) or terms of your policy say so: no trained, available, competent, experienced in network provider - access to in network care is too delayed - a special authorization was granted


network
network

2. Make sure your provider is "in Network" whenever possible

  • Consult the "find a provider" option on your online portal

  • call your insurance to request a list

  • confirm with the provider that their status is still "in network"


3. Document!

  • Take a screen shot or print the entry on the online insurance list and date it

  • Network lists are updated on a monthly basis - at best! Keeping evidence that the list was not up to date, and misled you to consult an out of network provider at a much higher cost, can force your insurance to indemnify you for the extra $



Network sizes vary according to the type of plan you have.

However, insurance lists of In Network providers must always be available to members.

It is well worth using In Network providers whenever possible... and appropriate!



Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

 

(424) 999 4705 - F (424) 226 1330

@the medical bill whisperer 2024

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